Appeals and Complaints
Steps to take if you have been denied covered medical benefits or want to file a complaint.
To Appeal a Health Plan Decision
Your plan is required to have an appeal process that gives you an opportunity to resolve disagreements about denial of a covered benefit:
For appeals involving urgent circumstances, the plan is required to respond within 72 hours in Stages 1 and 2.
To File a Health Plan Complaint
In addition to the appeal process for denial of a covered benefit, you also have the right to complain to the health plan about any aspect of its operations. Your plan is required to have a system to resolve complaints about such things as quality of medical care, choice of doctors and other health care providers, and difficulties with processing claims or disputes about a plans business and marketing practices. The plan is required to respond to your complaint within 30 days. The plans member handbook contains a description of the process and contact information for resolving complaints. If you are dissatisfied with the outcome of the plans complaint process, contact the appropriate State agency:
For complaints about quality of care, choice of providers or access to network providers:
NJ Department of Health and Senior Services
For complaints about business practices such as claims payment, member enrollment or termination of coverage:
NJ Department of Banking and Insurance
Note: The process for appealing a decision or filing a complaint is
For Medicare and Medicaid managed care appeals refer to Other Important Resources
Health Care Carrier Accountability Act
Signed into law in the summer of 2001 by Acting Governor Donald T. DiFrancesco, this legislation gives HMO members the right to sue their HMO if the member believes that the HMOs decision to delay or deny care has or will result in serious harm to the member. In most cases members will first appeal the HMOs decision through the external appeal process described above. However, the external appeal process can be bypassed in cases where serious harm to the member has already occurred or is imminent.